Participant Name
*
First Name
Last Name
Participant Phone Number
*
Participant Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
*
-
Month
-
Day
Year
Date
Age
*
Gender
*
Male
Female
T-Shirt Size
S
M
L
XL
2XL
I am attending the Heatwave trip from June 26 - July 1
*
Yes I am attending
Campus Life Club/School
*
Abington Heights
Blue Ridge
Crestwood
Dunmore
Elk Lake
Lackawanna Trail
Montrose
Mtn. View
North Pocono
Pen Argyl
Pocono
Scranton
Susquehanna
Valley View
Wallenpaupack
Western Wayne
West Scranton
Grade You're Going Into
*
9
10
11
12 (including '21 grads)
Primary Emergency Contact Info
Primary Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Secondary Emergency Contact
Secondary Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Medical
In case of emergency
Name of Physician
*
First Name
Last Name
Physician Phone Number
*
-
Area Code
Phone Number
Physician Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
I have had a physical within the last 24 months
Medical Insurance Company
*
Policy No.
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Allergies (check all those that apply and specific nature of allergic reaction):
*
None
Animals
Environmental
Medication
Food
Insects
Latex
Please specify the nature of allergic reaction
*
If none, type N/A
Parent/Guardian Name
*
Parent/Guardian Phone Number
*
Parent/Guardian Email
*
Signature:
*
I understand that by filling out this form and signing below, I am agreeing to pay the Registration Amount to attend this HEATWAVE Conference.
Your Signature
*
Clear
Parent/Guardian Signature
*
Clear
PAYMENT
*
I want to Pay Online Now
I will send a check written to "Campus Life" with Memo: Heatwave Reg. (mailed to: NEPA Youth For Christ 1613 Jackson St Scranton PA, 18504)
Registration Payment
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